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Using the FS-ICU Instrument: Understanding and Improving Family Satisfaction in a Neuro ICU. David Y. Hwang, MD Assistant Professor of Neurology Division of Neurocritical Care and Emergency Neurology Yale School of Medicine Jennifer Robinson, APRN Yale-New Haven Hospital.

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using the fs icu instrument understanding and improving family satisfaction in a neuro icu

Using the FS-ICU Instrument: Understanding and Improving Family Satisfaction in a Neuro ICU

David Y. Hwang, MD

Assistant Professor of Neurology

Division of Neurocritical Care and Emergency Neurology

Yale School of Medicine

Jennifer Robinson, APRN

Yale-New Haven Hospital

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Lori Harmon, RRT, MBA

Director, Program Development

Society of Critical Care Medicine

Mount Prospect, IL

Today’s webcast is supported by grant number R18HS021940 from the

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David Hwang, MD

Assistant Professor of Neurology

Division of Neurocritical Care and Emergency Neurology

Yale School of Medicine

jennifer robinson aprn neuroscience icu yale new haven hospital adjunct faculty yale university
Jennifer Robinson, APRN

Neuroscience ICU

Yale-New Haven Hospital

Adjunct Faculty

Yale University

using the fs icu instrument
Using the FS-ICU instrument:

Understanding and improving family satisfaction in a Neuro ICU

SCCM Project Dispatch Webcast 02/05/2014

David Y. Hwang, MD

Assistant Professor of Neurology

Yale Division of Neurocritical Care and Emergency Neurology

Jennifer Robinson, APRN

Yale Neuroscience

disclosures
Disclosures
  • David Y. Hwang, MD
    • American Brain Foundation Practice Research Training Fellowship
    • Remedy Pharmaceuticals, Inc. (GAMES-RP clinical trial site PI)
    • Bayer HealthCare (legal consulting)
    • Oxford University Press (book)
  • Jennifer Robinson, APRN
    • None
outline
Outline
  • Importance of research on ICU family experiences
  • Available survey tools for assessing family satisfaction
    • Focus on FS-ICU
  • Multidisciplinary team approach at Yale for collecting survey data
  • Details of data collection setup, including troubleshooting problems
  • Recent survey results from Yale-New Haven Hospital Neuro ICU
  • Possible future directions
importance of research on icu family experiences
Importance of research on ICU family experiences
  • Institute of Medicine 2001 report
    • Recommendation for healthcare delivery to be “patient-centered”
    • Shared decision making
    • Coordinated care
    • Physical/emotional support
    • Culturally competent

IOM. National Academies Press 2001

importance of research on icu family experiences2
Importance of research on ICU family experiences
  • As of October 2012, the Affordable Care Act ties consumer satisfaction to hospital reimbursement
  • Medicare withholds 1% of normal reimbursement for a “bonus fund”
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey
    • Assesses patients’ perception of care
    • Scores factored into bonuses

www.washingtonpost.com/blogs/wonkblog

importance of research on icu family experiences3
Importance of research on ICU family experiences
  • Does family satisfaction with ICU care correlate with long-term family outcomes?
    • Caregiver burden for survivors
    • Grief and bereavement for nonsurvivors
    • Postintensive care syndrome (PICS-F)
      • Anxiety
      • Depression
      • PTSD
      • Acute Stress Disorder

Rothen et al. CurrOpinCrit Care 2010;16:623

Davidson et al. Crit Care Med 2012;40(2):618

importance of research on icu family experiences4
Importance of research on ICU family experiences
  • Despite existing controversies and uncertain influence of family satisfaction on long-term patient and family outcomes:
    • Satisfaction with medical care has become an important quality metric;
    • Surveys such as HCAHPS typically capture satisfaction data from patients themselves over the course of an entire hospital stay;
    • Quality improvement in ICUs should ideally be guided by ICU-specific information;
    • ICU family satisfaction research has thus received increasing attention over the past decade.
available survey tools for assessing family satisfaction
Available survey tools for assessing family satisfaction
  • Critical Care Family Needs Inventory (CCFNI)
  • Critical Care Family Satisfaction Survey (CCFSS)
  • Family Satisfaction in the ICU (FS-ICU)
    • FS-ICU 34
    • FS-ICU 24

Kentish-Barnes et al. Crit Care Med 2009;37(10):S448

fs icu
FS-ICU
  • Initially designed as a 34-item survey
  • Half of items address satisfaction with overall care
  • Half of items address satisfaction with the shared decision making process
  • Survey refined and revalidated in 2007 as a 24-item version

Heyland et al. J Crit Care 2001;16(4):142

Wall et al. Crit Care Med 2007;35:271

Heyland et al. Crit Care Med 2002;30:1413

www.thecarenet.ca

fs icu1
FS-ICU
  • Available for free on the Internet
  • Items are mostly scored on a 5-point Likert scale
  • Each item can be scored out of 100 points
  • Some overlap with patient HCAHPS questions
  • Wide use in the literature
    • Multiple large observational cohorts
    • Used as outcome instrument for intervention studies

Heyland et al. J Crit Care 2001;16(4):142

Wall et al. Crit Care Med 2007;35:271

Heyland et al. Crit Care Med 2002;30:1413

www.thecarenet.ca

fs icu3
FS-ICU
  • 3 items for family members whose relatives died during ICU stay:
    • Length of unnecessary prolongation of life
    • Comfort
    • Support by care team during family member’s death
fs icu4
FS-ICU
  • Recent ICU interventional trial using the FS-ICU as outcome instrument
  • Qualitative analysis of write-in comments performed
  • Recurring topics
    • Timeliness of information received
    • Appropriateness of communication in the patient care area
    • Comportment (professional vs. rude communication)

Shaw, Davidson et al. Crit Care Med 2014;42(2):265

yale multidisciplinary team
Yale multidisciplinary team
  • Approval by local IRB
  • Multidisciplinary approach vital to success
    • Recruitment of diverse group
    • Low turnover of team
    • Core group of 5 members recruiting families
    • Led by physician and NP
    • Nursing leadership
      • CNS
      • ICU nurse manager
    • Physician assistant
    • Staff RNs
    • PA student
    • Unit business associate / secretary
nuts bolts of data collection
Nuts & bolts of data collection
  • Monthly reminders to group to sign up for “call schedule” (M-F)
    • Recorded in group Google calendar account
  • “On-call” responsibilities:
    • Patient selection
    • Enrollment
    • Data collection
  • Timeline
    • Window for recruitment 24 hours prior and 8 hours after discharge from ICU
  • Family member selection
  • Exclusion Criteria
    • Admission <72 hours, unless made comfort measures
    • Non English speaking
nuts bolts of data collection1
Nuts & bolts of data collection
  • Survey converted from paper to Google survey
    • Only de-identified information online
    • Family and patient demographics stored separately
  • Automatically inputs results into Excel spreadsheet
  • Expired patients collected separately
    • Mailed letter detailing research study and paper version of survey
    • ~1 month passed before contact
  • Additional patient demographics of interest collected
    • Attending of record
    • Code status
    • Insurance
    • Education of family member
    • Diagnosis
challenges
Challenges
  • Workflow
    • Time consuming
    • Harder once patient transferred out of ICU
  • Resources
    • No dedicated research assistant
    • Not funded
  • Technical Issues
  • Family Response
    • ~55% response rate for survivors
    • Interest
benefits
Benefits
  • Fostering teamwork
  • Involvement of bedside nurses in varied aspects of research
  • Exploring our own strengths and weaknesses
    • Waiting room
  • Feedback from families
neurocritical care society 2013 conference abstract
Neurocritical Care Society 2013 conference abstract
  • Satisfaction with Emotional Support Provided in a Neuroscience Intensive Care Unit Among Families of Surviving Patients with a Neurosurgeon Versus Neurointensivist as the Attending of Record
ncs abstract figure emotional support
NCS abstract figure: Emotional support
  • Families reporting complete satisfaction with emotional support
  • p = 0.04
ncs abstract conclusions
NCS abstract: Conclusions
  • In our NICU, neurosurgery families are more likely to be completely satisfied with the emotional support received from staff compared to neurology families.
  • Questions:
    • Does a longer average length of stay allow NICU staff to build more of a relationship with neurosurgery families?
    • Do families feel more support with dual teams & attendings (NICU and neurosurgery) following?
    • Do neurosurgery families feel more support with a neurosurgery attending who does not change weekly (vs. rotating intensivists)?
families with prior icu experience vs new to icu
Families with prior ICU experience vs. new to ICU

Hwang DY, Robinson J, et al. Crit Care Med 2013;41(12):S830

possible future directions
Possible future directions
  • Advantages of having ongoing ICU family satisfaction data collection:
    • Improved understanding of our local Neuro ICU at Yale
      • Can help target ICU resources for quality improvement
    • Approval by Institutional Review Board allows for ongoing analysis and publication/presentation of observational data
    • Built-in pre- and post-assessments for any future interventions or change in practice that the team wishes to pursue
    • Available pilot data for future grant applications
    • Multidisciplinary ICU team building
possible future directions1
Possible future directions
  • Future analysis may focus more on surveys from families of those patients who have been made comfort measures only in the Neuro ICU
    • Of note, prior analyses have suggested that families of patients who pass away during ICU admission tend to report higher satisfaction than those of patient patients who survive to discharge
  • We welcome collaboration with other ICUs collecting FS-ICU data
    • Increased observational power with larger number of surveys
    • Please e-mail us!

Wall et al. Chest 2007;132:1425

our team leaders at yale
Our team leaders at Yale
  • Kelly Poskus, MS, RN
  • Cindy Bautista, PhD, RN
  • Jessica White, PA-C
  • Meghan McAnaney, RN
  • Anna Coppola, RN
  • Maria Koursaris, RN
  • Nathaniel Anderson, PA student
  • Lavenita Smith, BA
  • Kevin Sheth, MD, FCCM, FAHA
  • Emily Gilmore, MD
  • David Greer, MD, MA, FCCM, FAHA, FNCS
  • Evie Marcolini, MD
thank you
Thank you!

David Hwang, MD

david.hwang@yale.edu

Jennifer Robinson, APRN

jennifer.robinson@yale.edu